The second edition of the International Headache Society classification defines headache associated with sexual activity as bilateral headache precipitated by sexual excitement (masturbation or coitus), which occurs in the absence of any intracranial disorder and which can be prevented or eased by ceasing sexual activity before orgasm.

The International Headache Society classification differentiates two types of headaches associated with sexual activity. Type 1 is a dull ache in the head and neck associated with the awareness of neck and/or jaw muscle contraction which increases with sexual excitement. It is also called preorgasmic headache. Type 2, so-called orgasmic headache, is a sudden severe (‘explosive’) headache which occurs in orgasm.

A third type of sex-related headache consisting in a holocephalic, late coital, long lasting headache, has been classified as a secondary headache disorder, since its clinical features (most severe in an upright position and improving with recumbency) are consistent with low CSF pressure headache.

Headaches associated with sexual activity are rare and only a few studies have investigated the epidemiological aspects. The exact prevalence of headache associated with sexual activity is unknown. Until 1986, 110 cases of headache associated with sexual activity had been reported in the available literature. In the only population-based epidemiological study, the lifetime prevalence was about 1%. It is likely that the prevalence of this headache is underestimated, since patients often feel embarrassed to report intimate details about their sexual activities. A 3-4:1 male to female ratio more is reported for headache associated with sexual activity. The mean age at onset is between 30 and 40 years old, with a first peak between the ages of 20 and 30 and the second between 35 and 44. About 22% of patients experiencing headache associated with sexual activity have preorgasmic, while the remaining 78% have the orgasmic variant. The mean duration of severe pain is similar for both types of headache associated with sexual activity (30 minutes), but the mean duration of milder pain is more prolonged with type 2 (4 hours vs. 1 hour). The time of onset, however, is by definition different for the 2 types. In type 2 it occurs simultaneously with orgasm or less than 5 seconds before, while in type 1 it has a mean time of onset of 150 seconds preceding orgasm.

Migraine is comorbid in 30% of type 2 patients as opposed to 9% of those with type 1. Comorbid primary exertional headaches are also seen in 35% of type 2 cases while only seen in 9% of type 1 patient .

The usual setting for both types is sexual intercourse with the patient’s usual partner; however, 1/3 reports it with masturbation as well. A certain percentage of patients report that they can terminate the headache by stopping sexual activity; 51% report that they can lessen the pain intensity by taking a more passive role. In most cases, these headaches seem to occur in bouts that recur over a period of weeks to months before resolving.

The exact pathophysiology of headache associated with sexual activity is unknown. The pathophysiologic mechanisms proposed for sexual headaches are largely speculative. It was supposed that headache associated with sexual activity exhibits as main mechanism a trigeminal vascular effect, but a definite muscular component is also present. Muscular contraction plays a major role especially in milder headaches that become more intense as the sexual excitement increases (type 1 headache associated with sexual activity). Lance proposed that Type 1 sexual headache arises from excessive contraction of neck and jaw muscles during sexual activity and might be avoided by conscious relaxation of these muscles during intercourse.

Explosive (Type 2) headaches are attributed to rapid increases in blood pressure and heart rate that occur during orgasm. Indeed during orgasm, blood pressure may increase by 40-100 mmHg systolic and 20-50 mmHg diastolic, and this physiologic change has been suggested to play a role in the genesis of headache associated with sexual activity. Studies indicate that patients who experience type 2 headaches may have impaired cerebrovascular autoregulation. The cerebral vessels of these patients may dilate unpredictably in response to low pH as compared to normal healthy control. Some authors suggest that there is a possible link between type 2 headaches and migraines, and have postulated a release of catecholamines, neurokinins and serotonin during HAS. High blood pressure, pre-existing migraine and psychological factors are predisposing factors. “Headache associated with sexual activity” is more common in middle-aged hypertensive or obese males. The partial response of orgasmic headache to triptan therapy indirectly supports a pathophysiological similarity to migraine.

Since the third type of headache associated with sexual activity resembles the clinical picture of a low pressure headache, it has been postulated to be pathophysiologically related to an acquired CSF leak. In particular it may arise from a tear or widening of a tear in the arachnoid mater during sexual intercourse.

Prognosis of headache associated with sexual activity is good and should be explained to the patient. There is no treatment in the acute phase. As a preventive step, sexual activity could be stopped during the bout of headache, and a passive role can be beneficial. However, headaches associated with sexual activity are not always benign. Presentation of headache can mimic conditions such as subarachnoid haemorrhage, vascular thrombosis, hemispherical infarction, reversible sensory disturbances and homonymous hemianopia. Thus, they can be confused with “thunderclap” headaches that occur during coitus and signal a sudden intracranial event, such as subarachnoid haemorrhage.

With the first episode it is mandatory to exclude potential life-threatening and disabling causes. There are estimates that subarachnoid hemorrhage occurs in 4-12% of cases of all cases of headache occurring during sexual activity (3). An accurate anamnesis can help to differentiate the benign coital headache from more malignant causes such as subarachnoid haemorrhage: isolated coital cephalalgia is usually repetitive, unpredictable and episodic, while severe headaches lasting for more than 24 hours or associated with a loss of consciousness are unlikely to be headache associated with sexual activity.

However, a prompt and thorough neurological examination is imperative, as well as evaluation for vascular abnormality or subarachnoid hemorrhage with brain CT and lumbar puncture (if within hours of the onset) or brain Magnetic Resonance Imaging (if days or weeks have elapsed). This is especially important when the headaches are explosive (type 2). In fact, to meet the International Headache Society criteria for the diagnosis of headache associated with sexual activity, structural causes must be excluded.

Orgasmic headache can be frightening, distressing and disabling. After serious underlying pathology has been excluded by the appropriate investigations, the most important aspect of treatment is to reassure the patient and partner about this usually benign, self-limited disorder. In the majority of patients the headache disappears without any specific treatment. Nevertheless, acute or prophylactic treatment can be necessary in patients with severe acute pain or with repeated attacks. Follow-up studies investigating headache associated with sexual activity prognosis showed recurrence rates from 33% to 50% after 6 years. The presence of concomitant primary headache syndromes (migraine or tension-type headache) was hypothesized to be a risk factor for recurrence of headache associated with sexual activity. Concomitant exertional headache and an early onset of the disease seem to be associated with an episodic course of headache associated with sexual activity, whereas a later onset of the disease seems to be associated with a chronic course. headache associated with sexual activity attacks are usually short lasting without need for acute medical treatment but the duration of pain varies widely. About 15% of patients suffer from severe pain for 4 h up to 24 h, necessitating effective acute treatment. Indomethacin has also been suggested for acute treatment of headache associated with sexual activity, showing good results in 90% of cases. Triptans seem to be an alternative option for those patients not tolerating indomethacin. For triptans with low absorption rates (such as naratriptan), earlier administration 60 min before sexual activity may be favourable. For those patients with longer lasting bouts or with a chronic course of the disease, prophylactic treatment can be indicated. beta-blockers (propranolol or metoprolol) can be recommended for prophylaxis of headache associated with sexual activity, with success rates of approximately 80%.

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